Post on 12-Aug-2019
Bulletin of High Institute of Public Health Vol. 39 No. 2 [2009]
*Community Health Nursing, Faculty of Nursing, Mansoura University, Egypt
282
Application of Objective Structured Clinical Examination in
Community Health Nursing Course: Experience of Staff
Members and Students
Amel Ibrahim Ahmed*, Sahar Mohamed Soliman*, Lamiaa Amin Awad*
Abstract: Objective Structured Clinical Examination (OSCE) is the most valid and reliable tool for evaluation of performance competency. There are different formats of OSCE to assess the cognitive and psychomotor skills as well as the knowledge recall and communication skills in an objective and consistent manner. It is important to involve students and examiners in changing or innovating of evaluation pattern. The present study aimed to investigate the perception and experience of staff members and students toward introducing OSCE as a new approach of assessment in community health nursing course. In addition to compare the applicability of using three different structured methods of simulated patient (Lay person with staff members, Staff members play double roles and
two staff members), in order to find out the most appropriate simulated patient method. The
study is a mix of quantitative and qualitative design. It was carried out at the fourth year community health-nursing students, totaling 160 students. All examiners (n= 16) and only 60 students participated at the focus group sessions. Results revealed that most of students and examiners were satisfied with the objectivity of OSCE and the variety of questions that increase the chance of gaining marks. The students' level of performance ranged from good to excellent in all stations for most of students. The study recommends introducing OSCE into the curriculum of community health nursing course and holding comprehensive training for staff members on being a simulated patient and examiner at the same time.
Key words: Objective Structured Clinical Examination; Community Health Nursing; Students; and staff experience; Simulated/ standardized patients
INTRODUCTION:
The Objective Structured Clinical
Examination (OSCE) is one form of
performance- based assessments; this
assessment was first introduced into
medical education by Harden in Scotland
1975(1, 2). OSCE has proven to become the
gold standard allover the world as a tool for
evaluating the clinical competency in view
of the fact that it fulfill all the criteria of an
ideal method of assessment, which
283 Bull High Inst Public Health Vol.39 No.2 [2009]
includes comprising validity, reliability,
objectivity and practicability or feasibility(3).
Accordingly, it reduce bias and
discrepancies in the assessment of clinical
competence (4- 8).
Objective Structured Clinical
Examination (OSCE) is an assessment
approach that is used to evaluate clinical
competence of health science
undergraduate students in a
comprehensive, consistent, and structured
manner, putting into consideration the
objectivity process by using an examination
format that instructs students to rotate
through a circuit of stations of clinical tasks
to increase the test reliability(2,9,10). In
addition, it addresses the assessment of
the three domains cognitive, affective, and
psychomotor at one point(11). Currently
OSCE becomes a popular tool for
assessing clinical competency in nursing,
for the reason of its main objective is to
evaluate students' skills and attitudes at a
higher level of integrated learning, which is
not possible with traditional evaluation
approaches. Studies have shown that
OSCE objectively evaluates various skills
including the ability to elicit vital information,
analyze and synthesize it, apply knowledge,
make sound clinical decisions, and
communicate effectively (12- 14).
There are different formats of OSCE
that have been used for health sciences
students including nursing students. These
formats include anatomical models to
enable students demonstrate practical
tasks, computer images to evaluate
students abilities to utilize information
regarding identification of certain health
conditions, risk factors or proper
intervention(15). In addition, standardized
patient/ stimulated patient (SP) which is a
simulation of a patient by an actor or other
layperson who is trained to present the
specified history and physical findings in a
standardized particular manner. Students,
faculty staff, or physicians could be trained
to act as SP(16, 17). This performance is
Ahmed et al., 284
repeated uniformly and consistently. The
advantage of standardized patients in
evaluation is presenting different students
with a similar challenge, thus it reduces
one important source of variability(18).
Furthermore, SP incorporates a wide range
of options resembling reality that allow
students to work out through a clinical
problem with little or no mistakes, permit
students to make life-threatening errors
without hurting a real patient, and provide
instant feedback so students that can
correct a mistaken action (17).
In nursing education it was approved
that OSCE can be used most effectively to
assess safe practice in terms of
performance of psychomotor skills, as well
as the communication and schematic
knowledge associated with their
application(19).
While using non- standardized patients
as an assessment of clinical skills for
students reduces the reliability and validity
of exam. In community health nursing,
patients or clients may complaint of
manifestations that beyond the students
abilities or out of the learned objectives. In
addition, the turn over of clients and
patients in community health settings is
high, which results in absence of desired
health conditions for students evaluation
and inconsistent chances for students to be
examined in an objective manner. In this
highlight of finding of Pierre et al 2004,
which indicated the necessity of using new
assessment tools with student and the
impact of OSCE in reducing injustice and
inconsistency of clinical evaluation(3), it was
necessary to introduce OSCE approach in
the community health nursing course as
evaluation methods. Accordingly, the
present study aimed to investigate the
experience of staff member/ examiners and
students toward OSCE as a new approach
of assessment. Furthermore, the study
compared the applicability of using three
different structured methods of simulated
patient (Lay person with staff members,
285 Bull High Inst Public Health Vol.39 No.2 [2009]
Staff members play double roles and two
staff members), in order to find out the
most appropriate simulated patient
structure method.
Methodology:
Study design:
The study is a mix of quantitative and
qualitative designs. The quantitative one is
a comparative design, which was used to
describe the students' performance allover
the Objective Structured Clinical
Examination (OSCE), in addition to
comparing the applicability of three
different methods in implementing
simulated patient stations.
The qualitative design was used to portray
the students and examiners' experience
with OSCE by using focus group
discussion (FGD) (20). According to Barrour
2005, The FGD is appropriate to draw- out
the voice of students in relation to
introducing a new method of evaluation.(21).
The study included research questions,
which are:
1 – What is the experience of students and
examiners with the application of OSCE?
2- What are the challenges that face
students and examiners in OSCE?
3- What are the views of students and
examiners about using different three
structure methods in simulated patient
stations?
4- What is the most applicable structure
method of simulated patient station?
Setting:
The study was carried out at Community
Health Nursing Department, Faculty of
Nursing, Mansoura University
Subjects:
Purposive convenience sample of
undergraduate fourth year community
health nursing students (160 students)
during the first semester of the academic
year 2008/ 2009, and only 60 of them
agree to participate in FGD.
Methods:
The study carried out through two main
phases:
Ahmed et al., 286
1- Preparation Phase included two
parts:
The first part included negotiation and
discussion with staff members of
community health nursing department.
Three meetings were held with staff
members of community health nursing
department, to discuss the challenges of
the traditional clinical evaluation method
and to illustrate the concept of OSCE. At
the first meeting, each staff member was
asked to collect literatures about OSCE.
During the second and third meetings, all
staff members became aware about OSCE
and started to prepare for the exam. This
followed by another three meetings to
assign exam preparation tasks for each
staff member, and continuously follow up of
the ongoing preparation processes, which
included the nomination of students groups,
preparation of exam statements, questions,
scenarios, evaluation sheets, equipments,
assigning tasks during the exam, and
printing of the approved exam. Moreover,
this phase included choosing of lay
persons from the faculty workers to act as
simulated patients. Those workers should
be able to read and write.
The second part is the training for
simulated patient exam that conducted
for staff members/ examiners and lay
persons who will act as simulated patients.
Role-play scenarios were developed and
used in this training, which was conducted
through out ten days, five days for each
group.
Furthermore, staff members trained on how
to evaluate students during different OSCE
stations, by using predetermined
competencies being evaluated. These
activities were in parallel with students
training of OSCE assessment process.
2- Implementation phase:
Students divided into four groups each
group involved 40 students, rotated
throughout the OSCE stations.
Stations' design: The OSCE included
three types of exams to test different skills
287 Bull High Inst Public Health Vol.39 No.2 [2009]
and abilities of students. A set of marking
criteria was drawn up for each station to
assesses each student objectively. OSCE
consisted of the following exams:
- Electronic exam:
Electronic exam was designed to test the
knowledge and recall skills of students to
identify risk factors, abnormal signs of a
certain health condition, normal pregnancy
signs and child growth. It consisted of four
stations each one lasts for one minute,
totally four minutes, and four marks.
- Procedure demonstration exam:
Procedure demonstration exam was
designed to test the practical skills; it
consisted of three stations each one lasts
for three minutes. Each student asked to
demonstrate one phase of a clinical
procedure. The duration of this exam was
12 minutes and seven marks; procedure
checklist was used as evaluation tool.
- Multiple simulated patient exam:
Multiple simulated patient exam was
designed to test the four skills domains
namely; knowledge and understanding,
practical, intellectual, and transferable skills.
It consisted of three simulated patient
stations each one representing a different
health condition in 10 minutes.
- The first simulated patient station is
"Lay person with staff member: A lay
person to act as simulated patient and a
staff member acting as examiner.
- The second simulated station is "Staff
member playing double roles": A staff
member to act as simulated patient and
examiner at the same time.
- The third simulated station is "Two
Staff member": It included two staff
members one acting as simulated patient
and the other is the examiner.
During each station of multiple simulated
patient exam students were evaluated by
using 5- points likert scale. This scale
structured to evaluate students'
competency in history taken (2 items = 10
scores), physical examination (5 items= 25
scores), interpersonal skills (9 items= 45
Ahmed et al., 288
scores) and health education (3 items= 15
scores), the total scores was 95. Then;
students were asked to record their
findings in a certain sheet that used to
confirm the observation scale marks.
Exam's scores:
Researchers used the gained scores to
compare the level of performance of
students at the different stations, in order to
predict its appropriateness for students.
Level of performance of students rated as
following:
Poor less than 50%, fair from 50% up to
< 65%, good from 65% to < 75%, very
good from 75% to < 85% and excellent
from 85% and more.
2- Data collection: Data was collected
by using:
- Focus Group Discussion (FGD) was
used to obtain the views of students and
examiners regarding the different
examination methods of OSCE.
Focus group discussion included two
groups:
The first group is "Group (A) students
FGD", and the second group is "Group (B)
examiners FGD". To
1-Group (A) Students FGD sessions
consisted of six sessions, each session
included 10 students, each session
consumed 45- 60 minutes. The total
consumed time was 4.5 - 6 hours
2- Group (B) examiners FGD sessions
consisted of two sessions each session
included eight examiners and consumed
45- 60 minutes. The total consumed time
was 1.5- 2 hours.
Students' Focus group questions:
Q1- Describe your experience with OSCE?
Q2- How did you feel about OSCE?
Q3- How did you think about fairness and
objectivity of each station?
Q4- How did you find the OSCE?
Q5- How did you feel about each simulated
patients' station?
Q6- What are the challenges that you find
in OSCE?
Q7- How did you find the surrounding
289 Bull High Inst Public Health Vol.39 No.2 [2009]
environment of OSCE?
Q8- How did you describe the questions
and scenarios' statements?
Examiners Focus group questions:
Q1 – Describe your experience with OSCE?
Q2- How did you find the surrounding
environment?
Q3- Describe the student challenges at
each station and how you overcome?
Q4- How do you think about fairness and
objectivity of each station?
Q5- How do you describe the statements,
questions and scenarios of OSCE?
Q6- Describe your experince as regarding
simulated patients' station?
Q7- What do you suggest to use OSCE
effectively in the future?
Q8- What are the challenges that you
found in OSCE?
Data analysis:
Quantitative data analysis
The quantitative data was analyzed by
using SPSS package, ONE- WAY ANOVA
was used to compare the mean difference
of students' scores at multiple simulated
patient stations.
Qualitative data analysis:
Thematic analysis was used to analyze
participants’ descriptions of their
experiences with OSCE. The interview
transcriptions were analyzed to search for
common themes and similarities, and also
variations among participants' views. Data
was coded and similar codes were
identified and grouped together under
categories and subcategories. Similar
categories were organized together under
common themes. To check the validity of
the findings, the three researchers
reviewed the raw data and clarity of
analysis in relation to the emerging
categories and agreed themes (21).
Ethical consideration:
All participants informed about the study,
and consents were obtained from them.
Students informed that there is no any
obligation to participate in the study and
they have the right to refuse to participate
Ahmed et al., 290
without any affection on their formal
assessment. All data was anonymised,
and names were replaced with a
participant number.
Results:
The study results are presented by
qualitative and quantitative data. These
results were divided into two main parts;
the first part describes the performance
and experience of students with Objective
Structured Clinical Examination (OSCE).
The second part illustrates experience of
examiners with OSCE.
Students' performance and experience
with OSCE:
As regards to students performance
Table(1) shows that the excellent level of
performance was observed at electronic
exam among 73.25% of students, followed
by 62.5% at procedure demonstration
exam. While the poor performance was
observed at multiple simulated patient
exam among 6.8% of students.
Table 1: Distribution of students according to their level of performance at
different OSCE stations
Stations
Level of performance of students N= 160
Poor Fair Good Very good Excellent
N % N % N % N % N %
Procedure demonstration exam
0 0 5 3.1 5 3.1 50 31.25 100 62.5
Mean± S.D 0 3.7± 0.28 4.4± 0.1 5.3± 0.32 6.4± 0.36
Mean 95% CI 0 3.3 : 4.1 4.2 : 4.5 5.2 : 5.4 6.3 : 6.5
Electronic exam 6 3.75 36 22.5 0 0 0 0 118 73.25
Mean± S.D 1± 0.00 2± 0.00 0 0 3.4± 0.5
Mean 95% CI 1.0 : 1.0 2.0 : 2.0 0 0 3.2 : 3.4
Multiple simulated patients exam
11
6.8 62 38.75 58 36.25
18 11.25 11 6.8
Mean± S.D 4.2± 0.16 5.1± 0.32 6.2± 0.23 7± 0.27 7.5± 0.9
Mean 95% CI 4.1 : 4.3 5.03 : 5.2 6.1 : 6.2 6.8 : 7.1 6.9 : 8.2
Total OSCE marks = 20 marks
0 0 6 3.75 15 9.4 64 40 75 46.8
Mean± S.D 0 11.4± 0.22 12.5± 0.31 14± 0.59 16.1± o.5
Mean 95% CI 0 11.2 : 11.7 12.4 : 12.7 13.8 : 14.2 15.8 : 16.3
291 Bull High Inst Public Health Vol.39 No.2 [2009]
Regarding to the perception of students
to the OSCE, during focus group sessions,
nearly one quarter of students (n= 14)
mentioned that OSCE was an organized
method of clinical evaluation. They also
recommended applying this method for all
practical courses. "OSCE was an
organized method of evaluation and I
recommend applying it for all practical
courses" (G= group, SE= session, S=
student) (G A: SE1: S 2, 5, 8, SE 3: S3, 4,
6, 9, 10, SE 4: S1, 5, 8, 9, SE 5: S5, 7 SE6:
S 8).
Other students (n= 10) felt that OSCE
needs high intellectual skills and high
speed in performance, and it tests a variety
of students' skills. Therefore, it is suitable
for evaluating all nursing students' clinical
performance. "It needs concentration,
depends on understanding and rapid
performance" (GA: SE1: S 6, 7, 10, SE6: S
1, 7), "It is suitable for evaluating students'
various skills" (GA: SE5: S 3, 6), "OSCE
tested students' different abilities" (GA:
SE3: S 5, 9, 10).
One third of students (n= 18)
mentioned that OSCE included a variety of
questions, which enabled them to gain
more marks and this was a positive aspect
of OSCE. "OSCE is very good, it is
composed of many different questions
which provided me with a chance to obtain
more marks" (GA: SE1: S2, 4, SE3: S4, 9,
SE6: S 6, 7, 8, 10, "OSCE covered most
outlines of the course" (GA: SE2: S 1,2,5,8,
SE4: S 5, 6, 7, G 5: S4, 5,7)
On the contrary, a few number of
students (n= 3) had negative views about
OSCE. They viewed the variety of
questions negatively. One of the students
commented that OSCE was not suitable for
all students. "OSCE is troubling because it
includes various questions" (GA: SE2: S 3
8, 9), "It is not suitable for all students" (GA:
SE1: S 8, 9)
More than two thirds of students (n= 38)
were happy about the allocated time for the
electronic exam and procedure
Ahmed et al., 292
demonstration exam, but they felt that the
allocated time for the multiple simulated
patient exam was inadequate. Most
students (n= 38- 46) had positive views
about electronic exam in terms of the
variety and clarity of questions, the
suitability of the exam environment, and
the adequacy of the allocated time for
these stations. About half of students (n=
28- 30) had a positive view of the
procedure demonstration exam's stations.
The positive aspects of these stations were
similar to those were in the electronic exam.
"The time at the stations in the electronic
exam was enough for answering
questions" (GA: SE1: S2-6, SE2: S1-7,
SE3: S 3-7, SE4: 6- 1, SE5: S3-5, SE6:
S7,8),
"The allocated time for the stations in the
procedure demonstration exam was
enough" (GA: SE1: S2-6, SE2: S1-7, SE3:
S 3-7, SE4: 6- 10, SE5: S3-5, SE6: S7,8)
"The statements of the electronic exam
were clear" (GA: SE1: S1,1-7, SE2: S4, 6-
10, SE3: S 1-8, 10, SE4: S 2- 8, 10, SE5:
S6-10, SE6: S 1,2,7-10)
"The questions in electronic exam were
expected & varied" (GA: SE1: S1, 2-7, SE2:
S4, 6-8, SE3: S 1-5, 10, SE4: S 1, 2- 8, 10,
SE5: S6-10, SE6: S 1, 2, 7-10)
"The electronic lab environment was
suitable" (GA: SE1: S2, 3-8, SE2: S2, 6-9,
SE3: S 1-5, 10, SE4: S 2, 3- 9, 10, SE5:
S6-10, SE6: S 1, 2, 7-10).
Table 2 illustrates the difference mean
scores of students at the multiple simulated
patient exams. Students' scores show a
significant difference among the three
simulated patient stations. This difference
appears among stations in all evaluated
items, and in the total scores. Students
gain the highest scores at the lay person
station, followed by staff member of double
roles, and the lowest scores gained at two
staff member station.
293 Bull High Inst Public Health Vol.39 No.2 [2009]
Table 2: Mean scores of students' marks in multiple simulated patient exam
Items
Simulated patient stations
Lay person with staff member
examiner
Staff member playing double roles
Two Staff member
Mean± S.D
Mean 95% CI
Mean± S.D Mean
95% CI Mean±
S.D Mean
95% CI
History taken 7.4± 1.7 7.1 : 7.7 5.8± 2.5 5.5 : 6.2 5.7± 2.3 5.4 : 6.1
F- test 27.9
P 0.000
Physical examination
13.8± 5.9 12.8 : 14.7
11.1± 6.4 10.1 : 12.11
9.9± 5.5 9.1 : 10.7
F- test 17.8
P 0.000
Interpersonal skills
33.4± 5.3 32.6 : 43.3
31.9± 8.2 30.6 : 33.2 31.2± 7.8 29. 9 : 32.3
F- test 4.3
P 0.014
Health education
10.1± 2.4 9.7 : 10.5 9.1± 3.3 8.5 : 9.5 7.3± 3.4 6.7 : 7.8
F- test 32.8
P 0.000
Total score 64.8± 10.5a
63.2 : 66.5
57.9± 15.2b
55.6 : 60.3 54.2± 15.00c
51.8 : 56.5
F- test 24.8
P 0.000
Table (3) shows the distribution of
students according to their level of
performance at the three simulated patient
stations. More than half of students
demonstrate a good level of performance
at layperson with staff member station
followed by nearly one-third at staff
member playing double roles station. On
the other hand, the poorest level of
performance was observed at two Staff
member station among 31.8% of students.
Ahmed et al., 294
Table (3): Distribution of students according to their level of performance at
different three simulated patient stations
Simulated patient stations
Level of performance of students N= 160
Poor Fair Good Very good Excellent
N % N % N % N % N %
Lay person with staff member examiner
3 1.9 31 19.4 88 55 25 15.6 13 8.2
Mean± S.D 44± 4.3 52.2± 2.4 63.7± 4.1 75.7± 2.5 86.9± 3.9
Staff member playing double roles
45 28.1 28 17.5 52 32.5 26 16.25 9 5.6
Mean± S.D 39.3± 7.1 52.5± 2.5 63.7± 4.4 74.7± 2.5 86.8± 3.5
Two Staff member 51 31.8 47 29.4 39 24.4 16 10 7 4.4
Mean± S.D 37.5± 7.3 52.3± 2.2 63.7± 4.2 76.2± 2.4 84.6± 4.5
Regarding to stress exposure in multiple
simulated patient exam, students viewed it
as the most stressful stations among the
whole of OSCE stations. More than one
quarter of students (n= 17) felt more
comfort with lay person rather than
interviewing staff members. They add that
lay person station is the least stressful
station followed by staff member playing
double roles which is less stressful, than
two staff members station.
"The lay people station was less stressful
because I was able to give health
education easily" (GA: SE1: S2,5, SE 2: S
8-10, SE 3: S3,4,6,9, SE 4: S 1,5-8, SE 6:
S 1, 6, 10)
More than one quarter of students (n= 20)
considered the time factor and presence of
examiners as observers to be other causes
of stress.
"Time factor and presence of examiners
as observers are other factors of stress"
(GA: SE1: S1,2,5, SE 2: S 7-10, SE 3: S3,
4, 6, 9, SE 4: S 1,5-8, SE6: S 1,3, 6, 10)
"The presence of observer in simulated
patient stations made it stressful for me
"(GA: SE1: S1, 2, 5, SE2: S 7-10, SE 3: S3,
4, 6, 9, SE4: S 1, 5-, SE 6: S 1, 3, 6, 10)
295 Bull High Inst Public Health Vol.39 No.2 [2009]
In relation to the fairness and
objectivity of OSCE, eight students
described multiple simulated patient exam
as an objective method of evaluation, and
the most reliable one was the lay person
with staff member as they felt that they
were interviewing a real patient. "A lay
people station was more objective and
near to reality" (GA: SE1: S1, 2, SE2: 2, 10,
SE3: S5, 6, SE6: S7, 8)
On the other hand, two students
preferred stations of two staff members,
and described it as more objective, "Staff to
staff station was the most fair" (GA: SE 1:
S1, SE 3: S4)
The level of difficulty of simulated
patient stations as perceived by few
students depended greatly upon the type of
health condition that included in the
scenario (n= 6).
"The Typhoid scenario was difficult, for me
the AIDS scenario was the most difficult
one, and the pregnancy toxemia scenario
is the easiest" (GA: SE 4: S2, 3, SE6: S5, 7,
SE 3: S1, 6)
Some students (n= 14) described the
lay person station as difficult, for the
reason of that lay persons have limited
information about the health condition they
were acting. These information did not
beyond the mentioned information in the
scenario, "The lay person station was the
most difficult, they do not have enough
information about the health condition that
the act" (GA: SE3: S1, 2, 4, 5, SE4: S2, 1,
4, 7).
Another six students considered
scenarios not clear enough because they
needed more manifestations to be
mentioned. While other students (n=14)
described the scenario statements clear
enough, "Some questions were not clear;
there was a need for including more
manifestation”. (GA: SE 1: S3, 4, SE2: S 5,
6, SE3: S1, 2, 5, 6, SE4: S1, 9, SE5: S1, 2,
8, SE6: S 2, 3)
Ahmed et al., 296
Feelings and interpersonal relations
affect the acceptance of students to
simulated patient stations. The
interpersonal relations were described in
terms of cooperation of examiners to help
students, some students (n= 15) expect
more clarification from examiner to enable
them to catch the correct answer. In
addition, facial expression of examiners
sometimes affects the students' confidence
about their answers. Some students did not
like staff member to play the role of
simulated patient because some of them
may loss control of their facial expression,
which indicates that students are going to a
wrong answers. "Staff members were not
cooperative"(GA: SE 1: S5, 6, SE2: S1, 2,
SE 3: S8, 10, SE 4: S2, 10, SE5: S6, 7,
S4- 6),“The staff understands the scenario
and can facilitate my decision about the
condition" (G A: SE1: S7, 9, SE2: S3, 8,
SE3: S4, 5, SE4: S1, 7, SE5: S9, 10, SE6:
7, 8)
Examiners' experience with OSCE:
The majority of examiners (n=14) found
OSCE an objective, fair and
comprehensive evaluation method. "OSCE
is an objective and comprehensive method
of evaluation", (G= group, SE= session E=
examiner), (GB SE1: S3, SE 2: S5). In
addition, they found OSCE to have
advantages for both students and staff
members. Most of examiners (n=12) said,
"OSCE is a very useful experience that
measures several skills of students and
add new skills to staff" (GB: SE1: E1-7,
SE2: E2, 3, 6- 8).
Examiners described the surrounding
environment as unsuitable for the exam
due to the large number of students, and
the absence of air-conditioning at some
stations. "The environment was not
suitable in the computer stations due to the
crowding and the absence of air
conditioning. But it was suitable at skill lab
and simulated patient stations" (GB: SE1:
E 2, 7, 8)
297 Bull High Inst Public Health Vol.39 No.2 [2009]
In addition, a large number of
examiners (n=13) described the exam
statements to be clear, but the allocated
time for all stations was inadequate,
"Statements were clear" (GB: SE1:E1, 3-6,
SE2: E2 -8, "Time was not enough at all
stations" (GB: SE1: E2-7, SE2: E3-8).
However, examiners accepted multiple
simulated patient exam, as they found it a
proper method to simulate the reality, and
a good opportunity to observe the students'
behaviors with a patient, "OSCE give
chance to observe how students will
behave as if they deal with a real patient"
(GB: SE1: E 2, 4, 7, 8, SE2: E5,6,8).
Regarding to staff members who played
double roles, they did not feel any
confusion, and they felt and behaved like a
patient. "I felt and behaved like a patient"
(GB: SE1: E 1- 4, 7, 8, SE2: E1-6, 8), "I did
not feel any confusion" (GB: SE1: E 1- 5, 8,
SE2: E2-6,8). Only two examiners
mentioned that they experienced pressure
form students.
"Some students tried to extract the correct
answer by asking a direct question",
"I felt imposing by students, they asking a
direct question such as "do you complain of
bilharzias or ascaris" to obtain the answer
of the exam", "I was stressed when some
students tried to get my approval for their
answers and/ or the health education that
they give (GB: SE1: E 3,4).
One examiner found that double roles
station may make staff overloaded when
starting to write the student's marks, while
students' were starting to ask again about
the scenario. "I felt confused between the
double roles as patient and examiner for a
while if examinee ask about scenario
condition once again, but I did not loss
control", "I was overloaded". (GB: SE1: E 3)
As regards to lay person station, two
staff members found it typically simulating
the reality, but it was difficult to train lay
persons who did not show enough
cooperation. In addition, lay persons kept
in their minds the scenario dialog only, and
Ahmed et al., 298
they could not answer any more questions
that students arise. "When students were
asking about the manifestations or risk
factors that were not mentioned in the
scenario the lay person could not answer"
(GB: SE2: E 3, 4)
Examiners found that the two staff
station is less exhausting, and facilitating
the evaluation process, but it needs a large
number of staff members. "Two staff
station does not provoke exhaustion, but
the examiners may loss concentration" (GB:
SE2: E 1, 6), "Two staff station needs a
great number of staff members" (GB:
SE1:E1-6, 8 GB: SE2: E2,3, 5-8), "Two
staff station is better, it facilitates the
evaluation process" (GB: SE1: E 2, 4, 7, 8,
SE2: E5, 6 , 8)
Examiners described the students'
challenges with OSCE in terms of large
number of students and shortage of staff
members, which makes students to wait for
a long time, accordingly; their anxiety
increased. Ten staff members out of
sixteen recommended staff with double
role station to be used in the next
academic year. "It is better to use examiner
as a patient at the same time" (GB: SE1:
E1, 3, 5, SE2: E2, 4)
Discussion:
Objective Structured Clinical
Examination (OSCE) is a practical test to
assess specific clinical skills, which is a
well established method of assessing
clinical competence. (8,22, 23) The study
findings present important perspectives of
admitted students to OSCE at community
health nursing course. A student's view
about OSCE is approximately similar in
several studies. They view OSCE as
helpful in identifying areas of weakness; it
is a comprehensive, fair, and objective
evaluation method (3, 10, 24). The present
study showed general positive views of
students toward OSCE in terms of proper
organization, objectivity, and fairness. In
addition, they described it as a
comprehensive either for covering most of
299 Bull High Inst Public Health Vol.39 No.2 [2009]
learned topics and course objectives, or
the scope of measured skills especially
intellectual skills. One benefit of this
comprehensive evaluation method is
collection of marks as mentioned by one
third of participants. These results are
confirmed by the quantitative marks of the
registered students (table1), as nearly half
of them demonstrate excellent scores and
a minimal percentage had a fair scores,
although the variation of performance level
within the three types of examination that
used in OSCE.
The present study is in agreement
with several studies that used OSCE for
students in different health sciences.
Health sciences' students approved that
OSCE covers a wide range of clinical skills,
competencies and, knowledge; in addition,
chance of failing was minimal, as reported
by Awaisu et al 2007 and Pierre et al 2004
(3, 10). Furthermore, the present study in
agreement with Khursheed et al 2007 who
mentioned that the majority of students
agreed that the given tasks of OSCE were
clear and easily understood.(25) On the
other hand, some participants of the
present study had negative perspectives
regarding to OSCE. These negative
perspectives were expressed in terms of
limited allocated time in some stations that
provoke feeling of stress among students.
This negative view reported in other
studies to be intimidating and more
stressful than other assessment format (3, 10,
24). Specifically, when OSCE introduced to
nursing students in Ireland, it was
perceived to be a meaningful and fair form
of assessment, although they
acknowledge the OSCE as a stressful
experience (26, 27).
Results of examiners' experience with
OSCE approved the positive and negative
views of students about OSCE in terms of
objectivity, comprehensiveness, and wide
range of evaluated skills. This findings in
agreement with Iqbal et al 2009, who
reported that all staff members who
Ahmed et al., 300
participated in their study perceived OSCE
to be an excellent tool for summative
assessment that portray the level of
different skills of each examinee (24). In
addition, they discussed that time limitation,
uncomfortable environment at some
stations, waiting for long time due to large
number of students and shortage of staff
members are the reasons of students'
anxiety. This in agreement with Barman
2005 who recommended triplications of
OSCE circuits was to reduce time and
subsequently students' anxiety will be
reduced (4).
Nowadays, simulation is taking an
important place in training and evaluation
of healthcare professionals. As regarding
to multiple simulated patient exam,
students found it the most difficult and
stressful one. They referred feeling of
stress to the presence of observer, level of
cooperation and uncontrolled facial
expression of simulated patients. Stress
was decreased at Layperson with staff
member as they felt more comfort to obtain
health history, performing assessment and
giving health education. Feeling of stress
and difficulty was provoked at stations
where staff members playing double roles,
but it extremely exceeded at two Staff
member's station. The uncooperative
simulated patients viewed by students to
be lay person who have limited information
about the condition that they are acting, or
staff members who disappoint their trails in
obtaining a direct answer about the
condition that mentioned in the scenario.
Findings of Khursheed et al 2007 and
Peckler et al 2009 confirmed the present
study in relation to effect of simulator's
response or behavior on students'
performance in OSCE (25, 28). Examiners
declared that they found difficulty to train
laypersons and they did not demonstrate
enough cooperation during exam. These
findings are confirmed by a study
conducted at Michigan University which
revealed that lay persons did not portray
301 Bull High Inst Public Health Vol.39 No.2 [2009]
the patient in the manner expected (29).
Furthermore, examiners pointed out that
students tried hardly to pull out the correct
answer from them.
There was variability in students' views
about objectivity and fairness of multiple
simulated patient exam. Some students
referred objectivity and fairness to the
reality in simulation that they felt in
layperson with staff examiner station. While
others found staff stations is more objective
due to the understanding of staff members
to the health condition when they acting as
simulated patient. So it could be an
advantage of using staff members to act as
simulated patient in the highlight of the
findings of Lovell et al 1998 who stated that
medical student- simulated patient
understood the purpose of simulation and
medical condition portrayed (29). Students
have a suspicion that the objectivity of the
evaluation will be reduced when staff
member acting as simulated patient,
especially when playing double role.
Concerning this point staff member
revealed that they felt confusion between
the double roles they acting for seconds,
but they did not loss control at all.
Quantitative marks confirm the view of
students regarding different type of
simulated patient stations. Students
obtained the highest marks at "layperson
with staff member examiner" station
followed by "staff playing double role"
station.
Examiners stated that multiple
simulated patient exam is a chance to
closely observe students' performance in a
well reality-simulating situation. The
present study is confirmed by several
studies which recommended using SP in
assessing nursing students for the reason
that examiners and students found it a
reliable and valid means of assessment (30- 32).
Conclusion:
In conclusion, all the academic staff
members were satisfied with applying
OSCE in community Health Nursing course;
Ahmed et al., 302
they appreciated the learning experience
and the objectivity manner of the exam.
Some students indicated that OSCE was
stressful but they felt they well prepared
and appreciated the efficacy and relevance
of this assessment method. While other
students described OSCE to be, stress
provoking experience and requires
considerable preparation effort for students
and examiners. All students mentioned the
electronic exam stations and procedure
demonstration stations were clear, earn
marks also time and environment were
suitable, while multiple simulated patients
were the most stressful stations and the
time was not enough. Most of participants
approved to use one staff member to act
as simulated patient and examiner at the
same time.
Recommendations
1- Use OSCE in formative and summative
evaluation
2-Persons who acts as a simulated patient
must be understand the objective of OSCE
and trained well on essential issues which
are:
▪ How to act like a patient
▪ How to use scenario information
properly
▪ Controlling of non- verbal
communication
REFERENCES: 1. Rutter PM. The introduction of
observed structured clinical examination (OSCE) to M. Pharm. Degree pathway. Pharm Edu. 2002; 1: 173- 80.
2. Barman A.Critiques on the Objective Structured Clinical Examination. Annals Academy of Medicine.2005,34(8):478-482.
3. Awaisu A, Mohamed HNM, Al- Efan AMQ. Instructional design and assessment: Perception of pharmacy students in Malysia on the use of objective structured clinical examination to evaluate competency. American Journal of Pharmaceutical Education. 2007; 71 (6): 1- 7.
4. Barman A. Critiques on the objective structured clinical examination. Ann Acad Med Singapor, 2005; 34; 478- 82.
5. Bulfone G, Zanini A, Tosolini C, Zuliani S. The OSCE method (Objective Structured Clinical Examination) in the university course for nurses in Udine. Assist Inferm Ric. 2006; 25(3):176-80.
6. Corbo M, Patel JP, Abdel-Tawab R, Davies JG. Evaluating clinical skills of undergraduate pharmacy students using objective structured clinical
303 Bull High Inst Public Health Vol.39 No.2 [2009]
examinations (OSCEs). Pharm Edu. 2006; 6: 53- 8.
7. Rentschler DD, Eaton J, Cappiello J, McNally SF, McWilliam P. Evaluation of undergraduate students using Objective Structured Clinical Evaluation. J Nurs Educ. 2007; 46(3):135-9.
8. Ahmed C, Ahmed N, Abou-Bakar R. Assessing nursing clinical skills performance using objective structured clinical examination (OSCE) for open distance learning students in open university Malysia., International Conference on Information; Kuala Lumpur. 12- 13 August 2009.
9. Harden RM. What is OSCE? Med Tech. 1988; 10: 19- 22.
10. Pierre BR, Wierenga A, Barton M, Branday MJ, Christie DCC. Student Evaluation of an OSCE in pediatrics at the University of the West Indies, Jamaica. BioMed Central Medical Education. 2004; 4: 22. http://www.biomedcentral.com/1472-6920/4/22.
11. Shaw LMA. Effective assessment of trainees. The Ob& Gynae. 2004; 6: 171- 77.
12. Cohen R, Reznick RK, Taylor BR, Provan J, Rothman A. Reliability and validity of the Objective Structured Clinical Examination in assessing surgical residents. American Journal of Surgery. 1990; 160 (3), 302- 5.
13. Singh R, Singh A, Anderson RD, Singh G. A patient safety objective structured clinical examination. J Patient Saf. 2009; 5 (2): 55- 58.
14. Carraccio C, Englander R. The objective structured clinical examination, a step in the direction of competency- based evaluation. Arch Pediatr Adolesc Med. 2000; 154: 736- 41.
15. Holyfield J L, Bolin AK, Rankin VK, Shulman DJ, Jones LD, Eden DeSB. Use of computer technology to modify
objective structured clinical examination. Journal of Dental Education. 2005; 69 (10): 1133- 1136.)
16. Guiton G, Hodgson CS, May W, Elliott D, Wilkerson L. Assessing Medical Students Cross-Cultural Skills in an Objective Structured Clinical Examination. Center for Educational Development and Research. 2004;1-12.
17. Kemahli S. Clinical Teaching and OSCE in Pediatrics. Med Educ Online 2001;6:10
18. Sadeghi M, Taghva A, Mirsepassi G, Hassanzadeh M. How do examiners and examinees think about role- playing of standardized patient in OSCE setting?. Academic Psychiatry. 2007; 31 (5): 358- 362.
19. Mitchell ML, Henderson A, Groves M, Dalton M, Nulty D. The objective structured clinical examination (OSCE): optimizing its value in the undergraduate nursing curriculum. Nurse Educ Today. 2009;29(4):398-404.
20. Kitzinger J. Qualitative Research: Introducing focus groups. BMJ. 1995; 311: 299- 302.
21. Barbour SR. Making sense of focus groups. Medical Education. 2005; 39: 742- 750.
22. Carpenter JL. Cost analysis of OSCEs (Review). Acad Med. 1995; 70: 828- 33.
23. Austin Z, O' Byrne CC, Pugsley J, Munoz LQ. Development and validation processes for an objective structured clinical examination (OSCE) for entry- to- practice certification in pharmacy: the Canadian experience. Am J pharm Educ. 2003; 67 (3): Article 76.
24. Iqbal M, Khizar B, Zaidi Z. Revising an objective structured clinical examination in a resource- limited Pakistani Medical School. Education
Ahmed et al., 304
for Health. 2009; 22 (1): 1-9. Available from http//www.educationforhealth.net/
25. Khursheed I, Usman Y, Usman J. Students' feedback of objective structured clinical examination: a private medical collage experience. J Pak Med Assoc. 2007; 57 (3): 148- 149.
26. Furlong E, Fox P, Lavin M, Collins R. Oncology nursing students' views of a modified OSCE. Eur J Oncol Nurs. 2005; 9(4):351-9.
27. Brosnan M, Evans W, Brosnan E, Brown G. Implementing objective structured clinical skills evaluation (OSCE) in nurse registration programmes in a centre in Ireland: a utilisation focused evaluation. Nurse Educ Today. 2006;26 (2):115-22.
28. Peckler B, Schocken D, Paula R. Simulation in a high stakes clinical performance exam. Journal of
Emergencies, Truma, and Shock. 2009; 2: 85- 88.
29. Lovell L K, Mavis E B, Turner LJ, Ogle SK, Griffith M. Medical students as standardized patients in a second- year performance- based assessment experience. Med Educ. Online [Serial online] 1998; 4: 6. Available from URL http://www.utmb.edu/meo/
30. Walters J, Adams J. A child health nursing objective structured clinical examination (OSCE). Nurse Educ Pract. 2002; 2(4):224-229.
31. Alinier G. Nursing students' and lecturers' perspectives of objective structured clinical examination incorporating simulation. Nurse Educ Today. 2003;23(6):419-26.
32. Ryan S, Stevenson K, Hassell AB. Assessment of clinical nurse specialists in rheumatology using an OSCE. Musculoskeletal Care. 2007;5(3):119-29.